Psychologist Craig Bryan: Treating Vets For PTSD

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PTSD: Not A New Ailment On 'Wartorn' Battlefield

TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

Combat and post-traumatic stress disorders are nothing new, but in earlier
times, they were given other names like insanity and melancholia during the
Civil War and combat fatigue during World War II. Last week, General George
Casey, the Army's chief of staff, called PTSD the defining military health
issue of our era.

A little later, we'll hear from Dr. Craig Bryan, who advises both the Air Force
and the Department of Defense on preventing soldiers with PTSD from committing
suicide.

My first guests, Jon Alpert and Ellen Goosenberg, directed a new documentary
about PTSD called "Wartorn: 1861-2010" that will be shown on HBO this Thursday,
Veterans Day. It's about how the recognition and treatment of PTSD has changed
from the Civil War to the wars in Iraq and Afghanistan. "Wartorn" uses
historical letters, photos and film, as well as contemporary interviews, some
of which were conducted by James Gandolfini. Alpert and Goosenberg also
collaborated on the HBO documentary "Alive Day Memories: Home From Iraq." I
spoke with them about their new film, "Wartorn."

Jon Alpert, Ellen Goosenberg, welcome to FRESH AIR. The movie early on has
Civil War letters from a soldier named Angelo Crepsy, who enlisted at the age
of 18. Before we hear an excerpt, tell us how you found these letters.

Ms. ELLEN GOOSENBERG (Filmmaker, "Wartorn: 1861-2010"): Trying to do a piece
about combat trauma in the Civil War is really difficult because there was no
documentation of combat trauma back in the Civil War, and there was no real
psychiatric diagnoses in the Civil War except for insanity. And so you have a
couple of options.

You can go to the records of insane asylums, or you can go to pension files.
And those were really the only recognition that there might be something wrong
with someone is their family would attempt to get a pension because their
breadwinner came home from the war and wasn't able to function psychologically.
And so going through these really unsexy legal documents led to a number of
stories, and as we began to research them, we were really looking for first-
person accounts because we thought that would make it a lot more compelling,
and we came across a number of those.

And in delving into them, we found Angelo Crepsy. What was extraordinary about
him is that his descendants kept all of his letters, and he was an incredible
letter writer. And he kept a diary, and there were photos. And all of those
were available to us.

GROSS: Well, let's hear an excerpt of the first letter that you use from him,
and this is after he's enlisted. It's 1861, and he sounds pretty confident.
It's addressed to a friend named Leroy(ph).

(Soundbite of film, "Wartorn")

Unidentified Man #1 (Actor): (As Angelo Crepsy) Dear Leroy: Camp life is not
home. A sergeant of Company D committed suicide. He seemed to be a little
shattered. He took his rifle and loaded it when there was no one about and put
the muzzle into his mouth and tugged the gun off with his toes.

There has been 100 or more of the boys who have gone home. They are cowards. I
won't disgrace my parents by deserting or turning back. A soldier's life is
hard, but I should be able to take care of myself.

GROSS: Okay, so that's a soldier's letter from 1861. He sounds pretty
confident. You know, he should be able to take care of himself. But after more
than two years, he writes a letter saying no one who has been a soldier can
imagine what a fighting man has to endure, how many men are ruined by this war.

And he's taken to an Army hospital feverish and delirious. And let's hear that
letter that's addressed to Leroy.

(Soundbite of film, "Wartorn")

Unidentified Man #1: (As Crepsy) October 12th, 1863. Dear Leroy: I am not so
well. I am clear off the hooks. They took me before the board, and they decided
to discharge me from the service. They say I will not be fit for the field this
winter.

GROSS: Ellen, let me ask you what happens after that letter.

Ms. GOOSENBERG: His father gets a call from the hospital, saying that if he
hopes to see his son alive, he needs to come pick him up, come visit him
because he's declining physically.

So the father goes, and he gets well enough to come home. But when he's home,
everyone notices that he's a completely different person than the one who left.
He's paranoid. He's in and out of reality. He attempts suicide several times
and doesn't complete the suicide. And then his friends are going hunting, and
he's in – they're all crack shots. I mean, this was what their unit was known
for.

And the friends don't want to take him because he's unstable, and they have no
idea what's going to happen. And the true story is he follows them, and one of
the guys kind of lags behind and says, you know, why don't you hang out in this
blind here, and, you know, we'll let you know when it gets interesting up
ahead.

And he takes that opportunity, alone in the woods, to shoot himself to death.

GROSS: And then you have people reading the court testimony following his
suicide. Why was there a court procedure following this suicide?

Ms. GOOSENBERG: Back in the Civil War, there was an opportunity to collect a
pension if you lost the breadwinner in war. In his case, he wasn't married, but
his father wanted to make a claim that the family was in need of the income he
would have provided.

And so there was a court procedure, and you had to marshal everyone that knew
the person to talk about whether or not they were a drunk before they went to
the war and whether they, in fact, you know, would have been capable of making
money and whether or not they were psychologically intact and all of that kind
of stuff. You really had to plead your case, and so this was basically a
pension hearing.

GROSS: Let's hear an excerpt of the testimony given by friends and family at
that hearing. And this is being read from the court papers.

(Soundbite of film, "Wartorn")

Unidentified Man #2 (Actor): (As character) I found him lying on the ground on
his back. His gun was between his legs, muzzle on his breast.

Unidentified Woman #1 (Actor): (As character) I remember that when my brother
Angelo came home from the Army, he looked wild, and when he was raving, it took
my father, mother and half-sister to tie him down to the bed.

Unidentified Man #3 (Actor): (As character) It seemed that something he did in
the Army preyed upon his mind and wounded him.

Unidentified Woman #2 (Actor): (As character) He seemed to be worried, and he
said everybody hated him because he had killed people.

Unidentified Man #4 (Actor): (As character) If ever a man's mental disorder was
caused by hardships endured in the service of his country, this was the case
with my son.

GROSS: So that's an excerpt from Jon Alpert and Ellen Goosenberg's movie
"Wartorn."

I think what interests me in the Civil War letters and in the court testimony
that we just heard is how well it seems to parallel what we're hearing now from
Iraq veterans and what we heard from Vietnam veterans.

And, you know, even the fact that they had to prove, in order to get the
pension money, that he killed himself as a result of being at war, and now vets
have to prove that they really do have PTSD, and it's difficult to prove
sometimes. Were you struck by the parallels?

Ms. GOOSENBERG: I think we all were. If you have any doubt that PTSD is a real
thing, or you think maybe PTSD happens because the war is good, or it's bad, or
you come home a hero, or you come home a villain, it's really irrelevant.
What's really relevant is that the experience of war causes psychological
damage.

GROSS: Jon, you've included a World War II training film in the film "Wartorn,"
and this is a film about psychiatric procedures in the combat area. It's an
Army film from 1944. Do you want to describe why you've used an excerpt of this
film in your film "Wartorn"?

Mr. JON ALPERT (Filmmaker, "Wartorn: 1861-2010"): I think starting in World War
II, they began to realize that people were coming back from these wars with
psychological ailments that they hadn't predicted. And they sort of didn't know
what to do about it.

They didn't know what to call it. They didn't understand completely why people
were suffering like this, and it was a rather crude attempt by the Army to try
and interview these people and begin to get an understanding of why they were
so badly damaged from the wars.

GROSS: Well, let's hear an excerpt from this 1944 U.S. Army film called
"Psychiatric Procedures in the Combat Area." So this is a series of interviews
with active-duty soldiers during World War II.

(Soundbite of film, "Wartorn")

(Soundbite of film, "Psychiatric Procedures in the Combat Area")

Unidentified Man #5: (Unintelligible). My last time up there I broke down. I
was sanctioned to leave (unintelligible) to them.

Unidentified Man #6: What do you mean you broke down?

Unidentified Man #5: (Unintelligible) the shelling we took up there had me
crying all night.

(Soundbite of music)

Unidentified Man #6: What's your trouble?

Unidentified Man #7: (Unintelligible) killed.

Unidentified Man #6: I can't hear you.

Unidentified Man #7: I can't stand seeing people killed.

Unidentified Man #6: Did you see people killed?

Unidentified Man #7: Lots of them.

Unidentified Man #6: What?

Unidentified Man #7: Lots of them.

Unidentified Man #6: What does that do to you?

Unidentified Man #7: Wounds me.

GROSS: So that's an excerpt of the World War II training film "Psychiatric
Procedures in the Combat Area."

So you did your own interviews for your movie with World War II veterans who
were still feeling the effects of the war. And one of the men says to you in
the old days, it was called battle fatigue, lack of intestinal fortitude, and
no one wanted that on their records.

What did some of the men tell you in the interviews about how they dealt with
the effects, whether they tried to cover it up, whether they felt there was
anyone they could talk to about it?

Ms. GOOSENBERG: Well, absolutely having combat stress or battle fatigue was
something that nobody wanted to own up to because you were a coward. You were a
malingerer. You were a goldbrick. You were somebody that was making it up.

And so it was absolutely not okay to be unwell psychologically during World War
II and certainly when you came home and you were expected to be a hero, and you
were expected to, you know, be somebody who was going to sort of march forward
in life. Nobody wanted to talk about it, and the VA, as one of the veterans
describes in the film, was absolutely overwhelmed.

And they were sort of, the guys were sort of dispensed some kind of a sleeping
pill or whatever and told to go home, and they'd be fine the next day.

So I think that what happened is that these men kept it inside. Some of them
drank, and some of them had huge marital problems, and they were unemployed.
And, you know, they suffered in all kinds of ways without realizing what was
wrong with them until this diagnosis came to be in 1980.

And sort of coincidentally, some of them were beginning to enter retirement
age, and they were starting to re-experience symptoms, which is now documented
that this happens. And so they were sort of kicked back to the VA, and all of a
sudden the VA said: Ah, maybe you have PTSD. And they were, to some degree,
incredibly grateful for that diagnosis. They finally understood what the hell
was wrong.

GROSS: My guests are Ellen Goosenberg and Jon Alpert. They directed the new
documentary "Wartorn: 1861-2010." It will be shown on HBO this Thursday,
Veterans Day. We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guests are Jon Alpert and Ellen
Goosenberg. They directed the new HBO documentary "Wartorn," which is about
post-traumatic stress disorder now and in the past, before the name actually
existed.

I want to play the excerpt of the interview that you do with the mother of a
soldier who committed suicide. His name was Noah Pierce(ph). Her name is Cheryl
Softich(ph). And she's talking about how her son couldn't escape the horrors of
serving two tours in Iraq and how he couldn't forgive himself for some of the
things he did and that he still had the urge to hurt and kill people. And I'll
let her pick it up from there, and she's describing her son and his suicide.

(Soundbite of film, "Wartorn")

Ms. CHERYL SOFTICH: The United States Army turned my son into a killer. They
trained him to kill to protect others. They forgot to untrain him, to take that
urge to kill away from him.

This was found in his truck, the last letter he ever wrote, one he never
planned to leave and one I never planned to share. And it says: I never planned
to be that one to leave a note. I am writing it sober, but I won't be for long.

Mom, I am so sorry. My life has been hell since March, 2003, when I was part of
the Iraq invasion. It has nothing to do with anyone. Don't stress about this. I
am freeing myself from the desert once and for all. I thought (BEEP) would get
better, but I was wrong.

(Soundbite of shuffling papers)

Ms. SOFTICH: Well, I'm getting drunk now, so I'm more opened up. I have been
planning on doing this a long time. Time's finally up. I am not a good person.
I have done bad things. I have taken lives. Now it's time to take mine.

GROSS: That's Cheryl Softich, reading an excerpt of the suicide note that her
son Noah Pierce left after serving two tours in Iraq.

Would you describe how Noah Pierce actually killed himself?

Mr. ALPERT: Noah Pierce took a pistol, got in his truck, drove to a remote
location, wrote a suicide note, took out all the photographs that he had of
himself and stabbed his – stabbed the photos on his driver's license, he
stabbed his picture on his ID cards. He took out his face because he couldn't
stand what he looked like, shot out the mirrors in his truck because he
couldn't stand to look at himself anymore then put his dogtags to his temple
and killed himself, shot himself right through the dogtag.

GROSS: And his mother asked the police for the dogtag, and she has that now.

Mr. ALPERT: She has the dogtag as part of basically a memorial that she created
for her son, in which she believes through a series of photographs shows his
transformation from a normal boy from Minnesota to somebody who came back from
the war in Iraq haunted by what he had done, couldn't escape it, and the only
way to put an end to the things that were inside his head was to shoot himself
in the head.

GROSS: Pete Chiarelli, who is the person in the Army who's overseeing the new
suicide prevention program for the Army, says in your film that he's trying to
establish the idea that invisible injuries like post-traumatic stress disorder
are as important as physical injuries like losing a leg. What is the military
doing that you know of to try to establish that and to try to prevent vets from
killing themselves?

Mr. ALPERT: Well, the military has made it easier to get diagnosed with post-
traumatic stress disorder. You don't have to prove that it was a specific
traumatic incident. It could just be the cumulative effect of being in a war
zone that has affected you in a way that you can't deal with.

So that makes it easier. That also means that there's going to be many, many
people who are in need of treatment, and the cost of treatment that society's
going to have to bear is really going to be quite substantial.

They have instituted perhaps the largest rollout of any psychological training
program in the history of the world. They have hundreds and hundreds of
psychologists who are being trained in some of the therapies that they think
will fix post-traumatic stress. So that's something that's unique and unusual.

They're sending health care monitors out with every unit, and they're also
trying to set the tone from the top, in which the generals for the first time
are talking about this.

So you don't have somebody like General Patton, who sees somebody with post-
traumatic stress and says that they're yellow-bellied sapsuckers, slaps them
and sends them back to battle. They're taking these people off the battlefield.

But you really have to wait to see what's going to happen because as my father
said, less talk and more ado. They're saying the right things. But this is
something that's very difficult to deal with in a martial atmosphere, in which
you're supposed to be tough, you're supposed to be resilient, things aren't
supposed to affect you like this. And now all of a sudden, they're saying: It's
sort of okay to be wounded. It's okay to be - to be psychologically damaged.
We're going to try to treat you and send you back.

But we'll see. It is significant. They're admitting this, and they're
committing the resources.

GROSS: Some of the interviews in your movie are done by James Gandolfini, who
is famous, of course, for "The Sopranos." How did you end up working with him
on documentaries? I think this is the second one you've done with him?

Mr. ALPERT: Yes, that's correct. Both HBO, Sheila Nevins, the director of
documentaries, and James Gandolfini, have a strong commitment to try and help
Americans understand what happens when we send our people into war.

And Jim Gandolfini, before he ever made a documentary, was going over to Iraq
and talking to the soldiers, trying to help them feel better, using his
celebrity to entertain them but also trying to understand what happens when
people go to war.

And it was interesting working with him because on his TV show, he plays a big,
tough guy who has psychological problems because of what he has to do in his
line of work. And the soldiers don't necessarily see him as Jim Gandolfini.
They see him as Tony Soprano, and they relate to him in a very direct and
honest way.

He would sit down, and, two seconds later, they would be telling him of their
deepest, darkest problems, like he was their brother or their father-confessor.

And to some degree, it's the same thing with the generals. I don't know why,
but they were talking to him in a very relaxed and candid fashion that, as a
reporter, I would find difficult to try and get them to speak the same way to
me.

GROSS: Jon, you mentioned your father was a World War II veteran and had told
you stories about the war and why he fought. So what kind of stories did he
tell you, and what impact did those stories have on you?

Mr. ALPERT: My father was a pilot in the Pacific, and he flew patrol routes,
squares up in the air, looking down at the ocean, hunting down Japanese
submarines. And that was about all he ever told us. He wouldn't tell us
anything else because they had sworn him to secrecy, and like a good soldier,
he didn't talk about this.

But he finally began to talk about it, and one of the reasons why he said he
didn't want to talk about it is that he wanted to put all that behind him and
get on with his life. This was a thing that a lot of the World War II guys
wanted to do.

And he said his hero was Cincinnatus, who was a soldier in Rome, a very
accomplished general, who then put down his sword and went back and became a
farmer. And he believed that this was the ideal of American patriotism, in
which common citizens go serve their country and then get back to their normal
civilian life.

And the problem with post-traumatic stress is that you come back, you can't do
it. You want to do it so badly. You want to be able to go to school. But when
the kids in there are talking about the football game, and you have battles
going on in your head, and you're just unable to sleep at night because you're
having nightmares because of all the things that you've seen, there are people
who can't do what my father was able to do, what Cincinnatus did, because they
have post-traumatic stress, and it's a lot of them. It's thousands and
thousands and thousands of soldiers.

GROSS: I want to thank you both very much for talking with us. Ellen
Goosenberg, Jon Alpert, thank you so much.

Mr. ALPERT: Thank you, Terry, really appreciate it.

Ms. GOOSENBERG: Thank you.

GROSS: Ellen Goosenberg and John Alpert directed the new documentary "Wartorn:
1861-2010." It will be shown on HBO this Thursday, Veterans Day. We'll talk
with a psychologist who treats PTSD in the second half of the show. I'm Terry
Gross, and this is FRESH AIR.
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Psychologist Craig Bryan: Treating Vets For PTSD

(Soundbite of music)

TERRY GROSS, host:

This is FRESH AIR. I’m Terry Gross.

The suicide rate of military service members and veterans has been rising since
the start of the Iraq War. My guest, Dr. Craig Bryan, is on the frontline of
suicide prevention. He is the lead consultant to the U.S. Air Force for
psychological health promotion initiatives as well as the U.S. Marine Corps
Suicide Prevention Program. He also treats active duty serviceman and veterans
for PTSD and works with those at risk for suicide. He served in the Air Force
and in 2009, was deployed in Iraq and directed the Brain Injury Clinic at the
Air Force Theater Hospital in Balad. Dr. Bryan is an assistant professor in the
Department of Psychiatry at the University of Texas Health Science Center.

Dr. Craig Bryan welcome to FRESH AIR. In the documentary "Wartorn," which is
about post-traumatic stress disorder, the mother of a vet who killed himself
says, the Army taught him how to kill to protect others; they didn't teach him
how to stop having that instinct. Has she managed to sum up a serious issue,
what happens to you after you come home when you've been taught to kill?

Dr. CRAIG BRYAN (Assistant Professor, Department of Psychiatry, University of
Texas Health Science Center): Well, I think it is a pretty remarkable insight
into sort of the paradox of working with service members. You know, part of
being an effective warrior, an effective service member and having an effective
military is training our individuals to no longer fear death, to use violence
and aggression and control the manners and an individual's return from war
zones, combat zones using those skills. And they're not necessarily taught how
those skills fit within, you know, the culture and the context of the United
States, where violence and aggression have a very different role to play within
daily basis in contrast to a combat zone.

GROSS: Now you've said that, you know, soldiers are trained to face death with
fearlessness. But does that training also make it easier to take your life?

Dr. BRYAN: We think in some ways that it is. Yes. We do know that one
protective factor for suicide is fear of death. If someone is afraid to die
they tend not to kill themselves. And so when you have a group of individuals
who have been conditioned to overcome that fear, in many ways they sort of have
what it takes to kill themselves.

Now, of course, you know, fearlessness about death is not enough. A person also
has to want to kill themselves. You know, just because you know how to or
you’re capable of killing yourself doesn't necessarily mean that you're going
to do it because if you don’t ever desire suicide, you know, suicide never
becomes an option. So it's a little bit more complex than just pure capability.

GROSS: So what are some of the things that you've come across from vets who
you've worked with that have made them think about or succeed in taking their
lives?

Dr. BRYAN: Yeah. Well, I guess first I would say that there is no such thing as
succeeding in taking one's life. And they kill themselves and they have a fatal
outcome, but...

GROSS: Yeah. I was so sorry about that word when I used it. Yeah.

Dr. BRYAN: ...there's no such thing as a successful suicide. What we do know
about some of the factors that contribute to those who die as a result of self-
inflicted injury, there tends to be intense psychological and mental suffering.
There is an extremely high level of agitation, oftentimes there's mood
disturbance, a sense that things are never going to get any better. We see what
we call cognitive constriction within the clinical field, which is - it's sort
of like tunnel vision, an inability to solve problems and to kind of think of
options and select a solution that would be optimal.

When I work with suicidal service members I often, you know, tell them if you
are able to solve this problem effectively, you know, suicide wouldn't even be
an option. It would be obsolete in many ways. And so what we often find with
the service members is they just - they're suffering intensely. It's an
agonizing suffering and they haven't been able to figure out how to eliminate
that suffering in a way that doesn't require them to die.

GROSS: At what point do vets come to you for help?

Dr. BRYAN: Unfortunately, in the vast majority of cases, if a veteran comes
forward for help it's usually when they are in extremely bad shape. The
military culture is not quite amenable to going and asking for help from
others, particularly from a medical standpoint. Medical personnel are often
seen as outsiders.

You know, when someone comes in for any sort of medical problem, you know, we
might profile them, we might temporarily restrict their duty, which is, of
course, a necessary condition for them to recover, but in a culture in which
being able to sort of grit your teeth, endure, press on, where that's sort of
the norm and that's valued, you know, coming in and asking for help poses a
risk to the service member. And so unfortunately, those who do come in for help
are usually in - very, very distressed at that point in time and it's a much
more complex and difficult process to help them out.

Right now in the military, depending on the branch of service, there's some
fluctuation, but on a, you know, overall, about three quarters of service
members who kill themselves never come into a mental health provider, never
reach out and ask for help. And so it's - they're out there somewhere but most
of us don't know where they're at. The treatment providers don't know how to
get to them to provide them the help that they need.

GROSS: Are you currently seeing people in active duty or mostly people who are
no longer in the service?

Dr. BRYAN: Right now most of the patients I'm working with are active duty
still.

GROSS: So if they come to you it's an admission that maybe they're not combat
ready anymore - that they're maybe not, you know, up to being in the military
anymore and they're afraid that that would be a blot on their record? Is that
what you're saying?

Dr. BRYAN: Right. Yeah. There's a significant fear. That's actually the number
one barrier to accessing mental health services within the military, is that
there is a concern that it will have some sort of negative impact on the
career. You know, the number one fear is, of course, they will be kicked out of
the military or they will be deemed no longer fit for duty. Some of the other,
you know, less important reasons that people provide are, of course, they might
- they believe that there will be some sort of limitation to promotion, to
special-duty status, to particular career fields that require very high levels
of health standards.

Now, of course, most of these beliefs, if not all of them, are false. We know
actually very well, studies have been done showing that interestingly enough
when service members come in for treatment their likelihood of being retained
on duty and maintaining their deployability status actually increases and
actually remains very high. But, you know, that's a perception that
unfortunately is quite prevalent within the military right now.

GROSS: You know what I'm thinking must be difficult for you as a psychiatrist -
I mean in the civilian world, I think any kind of therapist tries to help their
patients exercise their own freewill in the most productive way that they can.
But freewill is a little bit limited when you're in the service and, you know,
the Pentagon has decided that, you know, you are going back for another
deployment and you don't want to.

Dr. BRYAN: Right.

GROSS: You don’t have a choice there. So then what becomes your role as their
psychiatrist when they don't have a choice and they're being told to face death
and to face the possibility of having to kill when they feel like I'm done with
that? I can't do that anymore.

Dr. BRYAN: Right. First off, I'm a psychologist, not a psychiatrist.

GROSS: Okay. Thank you for correcting me.

Dr. BRYAN: So just a quick clarification. I know that sometimes we play similar
roles but slightly different training. But as a psychologist, I'll do mostly,
you know, behavioral therapy - sort of the classic talk therapy. And the way I
approach that because you do find that interesting dynamic within the military
quite often, not necessarily related only to deployment but many aspects of
military life, and that a huge part of it is to help service members understand
that actually they do have a choice. They do have the ability to exercise
freewill, although maybe the options that they have available to them are more
limited than it would be if they were, you know, not in the military.

And kind of to illustrate this or to provide an example is if you had a service
member like this who doesn't want to deploy again, but, yet, you know, they
have received orders to deploy overseas, what I would work with or talk with
that individual about is, you know, why did they join the military? And
oftentimes I will pose to them, it's like, well fine, then don't deploy. You
don't have to deploy. And, of course, they usually say I'm crazy and say or
I'll, well, I'll end up in jail. If I don't do it I'll be a deserter and I'll
end up in jail. And then I point out to them so there you go. So your choice is
deployment or jail. And it's not a good choice by any means.

And then what we do is we start talking with them about their ideals, their
principles, what is it they value in life, you know, what type of a person do
they want to be, why did they join the military. And, of course, what you
usually get from these individuals, you get themes like, well, I stand for
honor, integrity. I care about my family. You know, I want to provide for my
spouse or for my children. You know, you get these, you get them connected with
what they consider to be important and who they want to be.

And then once we've identified that you really kind of pose that choice to them
again and say, you know, you’ve made a commitment to the military and part of
that commitment is a sacrifice of some of your individual autonomy. And so as
you consider whether or not you're going to deploy with the military or go to
jail, which of these two options will help you to be the man or woman of honor,
integrity, a good parent, a good spouse, you know all of those ideals.

And when you frame it in that way usually people start to realize that okay, I
do have a choice and I don't like it - and I never ask a service member to like
of the choice, I'm just asking them to make the choice that will help them be
the person that they want to be so that, you know, they feel comfortable with
all of the decisions that they've made in life even when they're not the
decisions that they want to be making.

GROSS: And I'm going to tell you, listening to that I know that the correct
answer is supposed to be so I will deploy and continue with my military
responsibilities as opposed to going to jail. But really, like if you pose that
choice to me, I might think maybe I'll go to jail because probably I won't get
killed there...

Dr. BRYAN: Mm-hmm.

GROSS: ...whereas if I go to Iraq I might get killed and then my children might
not have a father and, you know, my spouse might not have a spouse and...

Dr. BRYAN: Right.

GROSS: Do you know what I'm saying? It doesn't - I'm not sure that that choice
makes it - would make it any easier for me.

Dr. BRYAN: Mm-hmm.

GROSS: I'm not in that position so I can't say.

Dr. BRYAN: Yeah. And, you know, if a service member were to respond with that,
you know, I certainly can't force you to make one choice or another. And what
we would do is engage in a conversation about what the consequences are
associated with okay, I'll go to prison instead. Say, okay, so how does that
help you become, you know, all of these things that you want to be? And if
that's your choice then that's your choice.

And, you know, I certainly cannot force your mind in many ways. All I can do as
a psychologist is help you to understand the ramifications of the decision you
make and hopefully help you to make the decision that is in your best interest
and that sort of most matches and aligns with who you are as a person, because
really that's the pathway to, you know, reduced suffering in life.

GROSS: My guest is psychologist Dr. Craig Bryan. He's a consultant to the
Department of Defense on suicide and mental health. We'll talk more after a
break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guest is Dr. Craig Bryan, a psychologist who treats veterans and
active-duty service members who have PTSD, and he works with those at risk for
suicide.

Now, from February to August of 2009, you were in Iraq in Balad, and you were
the director of the Traumatic Brain Injury Center for the 332nd Expeditionary
Aerospace Medicine Squadron, and you were working to improve mental resiliency
and to manage combat stress. What are some of the things that you saw there
that helped you understand in a very first-person kind - in a very firsthand
kind of way the kind of stresses that soldiers face that can leave them feeling
permanently scarred?

Dr. BRYAN: I think what, you know, the most eye-opening experience that I had
when I was deployed was what service members were most concerned about, their
most pressing needs on a day-to-day basis. Actually it wasn't sort of the
traumatic events. It wasn't, you know, the combat, seeing dead bodies, shooting
people, being shot at, being injured. Yes, those were definitely important. But
what most service members sort of talked about the most was sort of the day-to-
day just benign stressors. It was the, you know, not being able to sleep in,
you know, a comfortable bed, not having access to warm cooked food, not being
able to communicate with loved ones easily or being on - you know, during that
one phone call you get in two weeks, home to the family - just happens to be
the time when some insurgent, you know, launches a mortar and the mortar lands
on the phone line and basically kills the phone line, and so now you're not
going to be able to talk to your family for who knows how long.

And it was sort of just those, you know, every day little stressors that just
grate on the nerves of service members that I think slowly degrade their mental
resources and their resiliency. So that when big things happen, when the
explosions occur, when the gun battles happen, they sort of it's like they
don't have as much energy in their battery to kind of get through that. And
that's where we started to see more of the problems.

And so, what we started doing, when I was deployed to start working with
combatants on just how to deal with day-to-day stressors, how to make sure that
your sleeping as well as possible, maintaining physical health, so exercising
regularly, engaging in meaningful activities all geared toward keeping them
mentally fit. So that when the big stuff does happen, you're able to respond to
it much more effectively and you're not as limited or as impaired as a result.

Once we did find those individuals who came in, who were having more
significant combat stress reactions, the biggest difference that I found
deployed was, of course, once I - you know, back here in the States when you
are working with a service member with, you know, posttraumatic stress
disorders or some other combat related illness or injury is that it usually
happens months or years in the past. Whereas, when I was in Iraq, you know, the
explosion happened yesterday. And so I was seeing them in the hospital while
they were getting their, you know, the shrapnel removed from their body. We
were doing the evaluations very quickly and providing interventions, you know,
sometimes even within hours of an event, geared towards preventing long-term
problems that we often talk about and we see here in the United States.

GROSS: And do you think that's helpful, to immediately have some kind of
psychological counseling after a traumatic event, after you've been hurt?

Dr. BRYAN: I think if it's done in certain ways. There's certainly some
evidence, you know, like critical incident stress debriefing or management,
that's been found to be harmful when delivered immediately following a trauma.

GROSS: Like what - and why is it harmful?

Dr. BRYAN: What seems to be the reason why it's harmful is because in that
particular model individuals are forced to undergo some sort of a psychological
intervention in which they relive the account. And the fear - we don't know for
sure but the theory seems to be - is that it interferes with the natural
grieving and processing, you know, process over time. And so, there's just a
natural reaction. You know, if someone tries to kill you, you know, it makes
sense to be a little afraid and on edge and to have nightmares and dreams about
it. The issue is how does that individual sort of consolidate those memories
and create meaning associated with it? And if you get in too early and disrupt
that process by forcing them to undergo certain interventions, you can
basically - yeah, you can mess it up. Whereas, what we were finding is that
when you allow the individual to voluntarily engage in early interventions, we
get much more success.

GROSS: Were you in a position of having to decide whether somebody should be
taken out active duty because of PTSD or whether just some counseling would
help them perform their job better?

Dr. BRYAN: Yeah, I mean all military psychologists and psychiatrists certainly
are in that position to do it. While I was deployed I was not necessarily
making decisions about whether or not someone be retained on active duty. The
decisions I was making on a daily basis, were whether or not they should be
air-evaced out of the country for more - for higher levels of care, or whether
I could adequately treat the conditions there in Iraq.

GROSS: Were those hard decisions to make?

Dr. BRYAN: Yeah. I mean there were certainly, you know, some cases are
definitely more difficult than others. I think the most difficult decisions I
had to make - and I can, you know, I can still remember the cases very vividly.
There were some where I recommended, you know, the service member be returned
to the United States for treatment and they did not want to go back. And, you
know, they begged me. They pleaded. They were very distressed and it was an
extremely, you know, emotional and a difficult process for me. Because on the
one hand, I know the reason I'm deployed to Iraq is to maintain a fighting
force, and so in that sense I want to keep as many people in the fight as
possible. That's certainly what the patient wants, is they don't want to be,
you know, sent back to the United States. They want to finish their mission.
And so, in that sense, I'm violating this relationship aspect with my patient.
But at the same time, in the back of your mind, you realize that in order to
maintain a fighting force they need to be healthy. And you have to recognize
your limits in a combat zone, on what you can treat and what you cannot treat
effectively. Because, you know, in a combat zone, if someone is not
concentrating, if they're not sleeping well, you know, their reaction time is
slowed down. That's a difference between life and death. And it's not just for
that patient, but it's for all the other service members in their platoon,
everybody else who is affected by that one individual's decision-making
process. So it's - they are many days where it was a pretty clear,
straightforward, you know, decision but there were several times where it was
extremely, extremely difficult in figuring out what should be done.

GROSS: My guest is psychologist Dr. Craig Bryan. He's a consultant to the
Department of Defense on suicide and mental health.

We'll talk more after a break.

This is FRESH AIR.

(Soundbite of music)

GROSS: My guest Dr. Craig Bryan, a psychologist who treats veterans and active-
duty service members who have PTSD, and he works with those at risk for
suicide.

Some people will tell you that, you know, everyone in a war zone gets
posttraumatic stress disorder of one degree or another - that it's not possible
to be in war and to be shot at, or to shoot at, without being scarred by it and
without suffering some kind of, you know, psychological trauma. Would you agree
to that?

Dr. BRYAN: Well, I wouldn't say that everyone has a degree of PTSD because
they've been deployed. I would agree that everyone is affected by life
experiences. And I think this is one of the areas that I've certainly been
working on - is that, you know, we assume that in all cases, 100 percent of the
time, deployment must be bad for that very reason. And if you've been shot at,
if you've been in a life threatening situation, there is going to be a toll or
a consequences that have to be paid and it can't possibly be good. I think what
that fails to recognize, however, is that it's also possible for the very same
experience to have both positive and negative qualities. And when you talk with
service members, overwhelmingly, that's what they will report. You know, even
when you look at some of the prevalence estimates of PTSD, you know, coming out
of OEF/OIF, about 15 percent are estimated to have likely PTSD. But what that -
what people kind of overlook is that that means 85 percent of deployed service
members are doing reasonably well.

You know, yes, they've probably been affected in some way by their experience,
but it can be, we can have both positive and negative life experiences from the
very same thing. We use skills that we learn in combat zones. We, you know,
learn how to interact with others in new ways. We find a sense of purpose and
meaning. There's a clarity oftentimes that comes to what is my, you know,
mission in life - that oftentimes people come back and they feel like they've
sort of learned something about themselves and they're a better person because
of it.

GROSS: I think it's fair to say that we know now that posttraumatic stress
disorder always existed, even though we didn't have a name for it until pretty
recently. When you look back to the era of like battle fatigue and, you know,
other names that were used to describe what we now call PTSD, can you see a
similarity of symptoms and, but different ways that the military dealt with in
the past? And do you feel like you are able to learn from things that
historically were done wrong in terms of coping with it?

Dr. BRYAN: Yeah, I think so. And, I mean you can go as far back as the ancient
Greeks and you can see within their writings some hints of descriptors that
would suggest, you know, the possibility of PTSD. So, you know, as long as
there has been military and there has been war and humans have used violence
against each other, we have known that the consequences associated with that
are sleepless nights, nightmares, memories, agitation, being on edge, and
that's as long as we've had written language describing battle, we have seen
those descriptions.

I think what has changed is that within the past several decades, of course, we
have brought science to bear in understanding this problem. So it's not so much
just, kind of, opinions and ideas about what's happening now, but now we
actually have, you know, empirical evidence to know, you know, how does PTSD
affect people? And more importantly, I think the most important advance within
this arena is, of course, the treatments. Thirty, 40 years ago, we didn't know
nearly as much about how to treat PTSD and we didn't have what, you know, now I
mean, you know, we talk about prolonged exposure and cognitive processing
therapy as those are the treatments for PTSD, that's front-line. Those didn't
exist 30-40 years ago, at least in their current state. Although, you know,
people were talking about it and the ideas were there, we didn't have it
organized in a natural treatment package and then prove that it actually works.

GROSS: Dr. Bryan, thank you so much for talking with us.

Dr. BRYAN: Oh, thank you for having me.

GROSS: Dr. Craig Bryan is a consultant to the Department of Defense on suicide
and mental health. He is an assistant professor at the University of Texas
Health Sciences Center in San Antonio.

You can find links to NPR's coverage of PTSD and suicide in the military on our
website, freshair.npr.org, where you can also download Podcasts of our show.

(Soundbite of music)

I'm Terry Gross.

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